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Wednesday, April 18, 2012

Atul Gawande: "The Hot Spotters". Healthcare's version of Cash for Clunkers.

In this fantastic piece in the New Yorker, Atul Gawande explains how a community physician in Camden, NJ saved his local hospital millions of dollars by providing very focused free medical care to the patients who were most frequently admitted. Here in DC, the well-to-do pay upwards of $1500 annually to be part of a MD-VIP program, where their primary care physician is available to them 24-7 to address their medical needs. In Camden, the "most dangerous city in America," this physician was able to provide an MD-VIP type of service to some of the poorest and most at-risk patients in America, with astounding results. Gawande writes:
The Camden Coalition has been able to measure its long-term effect on its first thirty-six super-utilizers. They averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction.  
What are the keys to reducing costs in healthcare? Focus on the small population of uninsured who have many chronic medical conditions, and who frequent the hospital the most. One study showed that "frequent users comprise 4.5-8% of all ED patients but account for 21 to 28% of all visits." These are the patients where a relatively small amount of free but focused preventative care can result in a dramatic reduction in medical complications and healthcare costs.

I call this idea "healthcare's version of cash for clunkers" not to deride patients, but to emphasize where our efforts need to be most focused. When the US government wanted to reduce auto emissions, they realized that removing a single inefficient polluting old car from the roads had the same impact as trying to make marginal efficiency improvements in 10 newer cars. The conclusion was clear: it's efficient and logical to spend your money where you will have the most impact. The same applies in healthcare. Managing the chronic conditions of our poorest and sickest patients with focused caring preventative care costs much less managing the complications of those conditions.
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